Pressure ulcers in German hospitals: Analysis of reimbursement and length of stay

Objective

Hospital-acquired pressure ulcers are an important indicator of the quality of care. Most pressure ulcers are avoidable with a robust protocol for prevention, but prevention activities often have a low priority for senior management because the true costs to the hospital are not visible. Our aim was to raise awareness of the value of pressure ulcer prevention by estimating the excess length of inpatient stay associated with hospital-acquired pressure ulcers, and by assessing whether additional costs are covered by increased reimbursement.

Methods

National activity data for hospitals in Germany are available through the InEK Data Browser. Data were extracted covering discharges from German hospitals between January 1 and December 31, 2021. Cases were selected according to the presence of a pressure ulcer diagnosis using ICD-10-GM codes L89.0-L89.3. Information was extracted for the ten most common German Diagnosis-Related Group (G-DRG) codes in patients with a secondary pressure ulcer diagnosis on mean length of stay and average reimbursement. Ulcer-associated excess length of stay was estimated by comparing cases within the same G-DRG with and without a pressure ulcer diagnosis.

Results

Mean length of stay was higher in patients with a pressure ulcer than in patients with no ulcer by between 1.9 (all ages) and 2.4 days (patients aged ≥65) per case. In patients aged ≥65 years, 22.1% of cases with a pressure ulcer had a length of stay above the norm for the DRG. In the German system length of stay above the norm is not normally reimbursed. Excess length of stay between 1.9 and 2.4 days leads to a potential cost to a hospital of between 1,633€ and 2,074€ per case.

Conclusion

Hospital-acquired pressure ulcers represent an important source of cost for a hospital which highlights the potential value of effective prevention.

Strategies to preventing pressure injuries among intensive care unit patients mechanically ventilated in prone position: a systematic review and a Delphi study

Background

Although the incidence of pressure injury in the prone position is high for the mechanically ventilated patients in the intensive care unit, evidence-based strategies are still lacking.

Propose

To conduct a systematic review of current evidence, and to propose a series of strategies to prevent pressure injuries among mechanically ventilated patients with prone position in the intensive care unit.

Methods

The study was guided by the Medical Research Council framework. After a systematic review of current evidence of original articles, guidelines, expert consensus and theories, a strategy draft was developed. Then we invited 20 experts to modify and refine these strategies through two rounds of Delphi consensus method.

Results

After two rounds of Delphi process, the importance of coefficient of variation (Cv) and Kendall's coefficient of concordance in the strategies repository were 0.067 and 0.311, respectively. And the operability of Cv and Kendall's coefficient of concordance in the strategy draft was 0.055 and 0.294, respectively. Ultimately, we established 31 strategies for including 7 themes (assess risk factors, assess skin and tissue, body position management, skin care, nutrition, preventing medical device-related pressure injuries, education and supervision). In addition, we also developed a strategy framework to clarify our strategies.

Conclusion

According to the Medical Research Council framework, we developed 7 themes and 31 strategies to prevention prone-position pressure injuries among the intensive care unit mechanically ventilated patients. This study was considered to improve the clinical management of pressure injuries among prone position patients in the intensive care unit settings.

Shifting loads as a result of chair articulations and associated perfusion responses in the context of pressure injuries: An investigation with able-bodied individuals

Wheelchair users with spinal cord injuries experience pressure injuries at high rates, causing a decrease in quality of life and an increased financial burden. The soft tissue in the buttocks (beneath the ischial tuberosities) and lower back (behind the sacrum) experience large interface pressures over long periods while seated, putting them at high risk of pressure injury development. The goals of this research were to evaluate the ability of an articulating chair design to redistribute pressures on the body and to affect blood perfusion in the buttocks tissue over the ischial tuberosities. Using a unique, custom-designed chair developed for this research, pressure and blood perfusion were obtained for numerous seated positions that included recline, seat pan tilt, and back articulations. Reclining the chair back increased maximum pressures in the buttocks and lower back regions, while it decreased maximum pressures in the upper back and thigh regions. Increasing seat pan tilt, or rotating the anterior edge of the seat pan above the posterior edge, decreased maximum pressures in the buttocks and lower back regions and increased perfusion in the buttocks. Results suggested that using back recline and seat pan tilt together to create a whole-body tilt increased pressures in the back and decreased pressures in the buttocks. Changes in back articulation redistributed pressure in all back regions. Thus, the articulating chair design redistributed pressures in all areas of the body and promoted blood perfusion in the buttocks while seated. Pressure redistribution and perfusion promotion are fundamental to reducing pressure injury risk.

Tissue matters: In-vivo tissue properties of persons with spinal cord injuries to inform clinical models for pressure ulcer prevention

The prevalence of pressure ulcers in patients with spinal cord injuries has been estimated to be between 30% and 47%. Individuals with spinal cord injuries sit for a majority of the time, increasing the risk of developing pressure ulcers in the buttocks and thighs due to large internal stresses. Human body models have been developed to study the formation of pressure ulcers, yet a persistent limitation in these models has been the material properties used to represent the soft tissues in the buttocks and thighs. Specifically, soft tissue material property data have not included wheelchair users, such as those with spinal cord injuries. The goals of this research were 1) to determine the in-vivo material properties of soft tissue in the thighs and buttocks of individuals with spinal cord injuries and 2) compare these to properties obtained from able-bodied people. Results indicated that the proximal and middle thigh regions of those who had a spinal cord injury were softer than the same regions as able-bodied individuals, while the distal thigh regions were stiffer. These findings are vital because they indicate that models developed using properties from able-bodied individuals will not produce internal stress or strain magnitudes that represent individuals who have a spinal cord injury. This information suggests that models should obtain material property data sets from their desired population. Human body models must represent the population being studied if they are to inform clinical assessments and make accurate patient predictions.

A Quality Improvement Project Comparing Two Treatments for Deep-Tissue Pressure Injuries to Feet and Lower Legs of Long-term Care Residents

OBJECTIVE

To retrospectively examine clinical outcomes from a feasibility study that compared two treatment options for deep-tissue pressure injuries (DTPIs), including the clinical indicators increasing the risk of deteriorating DTPIs among long-term care residents.

METHODS

A retrospective chart audit of 40 DTPIs from 33 long-term care residents in two long-term care facilities was conducted to compare (1) polymeric membrane dressings (PMDs) with offloading and (2) a skin barrier film with offloading.

RESULTS

Of the 13 DTPIs treated with PMDs, only 23% deteriorated to a stage 3 or 4 pressure injury (PI), whereas of the 27 DTPIs treated with skin barrier film, 41% deteriorated to a stage 3 or 4 PI. The clinical factors found to increase the risk of developing and deteriorating DTPIs included weight loss, hypoalbuminemia, debility, dementia, coronary artery disease, and cerebrovascular disease.

CONCLUSIONS

The PMD group's DTPIs evolved into fewer open PIs despite having higher percentages of clinical indicators for DTPIs. The project findings support the use of PMD dressings for DTPIs; however, more robust research is warranted.

Deep Tissue Pressure Injuries: Identification, Treatment, and Outcomes Among Critical Care Patients

Deep tissue pressure injury (DTPI) is a serious form of pressure injuries. The condition remains invisible for up to 48 hours and then progresses rapidly to full-thickness skin and soft tissue loss. Many other conditions that lead to purple skin can be misidentified as DTPI, making the diagnosis difficult at times. A thorough history exploring exposure to pressure is imperative.

Chitosan hydrogel encapsulated with LL-37 peptide promotes deep tissue injury healing in a mouse model

BACKGROUND

LL-37 peptide is a member of the human cathelicidin family, and has been shown to promote the healing of pressure ulcers. However, the low stability of this peptide within the wound environment limits its clinical use. Chitosan (CS) hydrogel is commonly used as a base material for wound dressing material.

METHODS

CS hydrogel (2.5% w/v) was encapsulated with LL-37. Cytotoxicity of the product was examined in cultured NIH3T3 fibroblasts. Effects on immune response was examined by measuring tumor necrosis factor-α (TNF-α) release from RAW 264.7 macrophages upon exposure to lipopolysaccharides. Antibacterial activity was assessed using Staphylococcus aureus. Potential effect on pressure ulcers was examined using a mouse model. Briefly, adult male C57BL/6 mice were subjected to skin pressure using magnets under a 12/12 h schedule for 21 days. Mice were randomized to receive naked LL-37 (20 μg), chitosan gel containing 20-μg LL-37 (LL-37/CS hydrogel) or hydrogel alone under the ulcer bed (n = 6). A group of mice receiving no intervention was also included as a control.

RESULTS

LL-37/CS hydrogel did not affect NIH3T3 cell viability. At a concentration of 1-5 μg/ml, LL-37/CS inhibited TNF-α release from macrophage. At 5 μg/ml, LL-37/CS inhibited the growth of Staphylococcus aureus. The area of the pressure ulcers was significantly lower in mice receiving LL-37/CS hydrogel in comparison to all other 3 groups on days 11 (84.24% ± 0.25%), 13 (56.22% ± 3.91%) and 15 (48.12% ± 0.28%). Histological examination on days 15 and 21 showed increased epithelial thickness and density of newly-formed capillary with naked LL-37 and more so with LL-37/CS. The expression of key macromolecules in the process of angiogenesis (i.e., hypoxia inducible factor-1α (HIF-1α) and vascular endothelial growth factor-A (VEGF-A)) in wound tissue was increased at both the mRNA and protein levels.

CONCLUSION

Chitosan hydrogel encapsulated with LL-37 is biocompatible and could promote the healing of pressure ulcers.